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Introduction
Upper motor lesion may produce muscle
spasticity which increases the resistance against
normal movements.1 As spasticity may disturb
walking and functional abilities of patients,2
Address for correspondence: Amir H Bakhtiary, Physiotherapy
Department, Rehabilitation Faculty, Semnan University of
Medical Sciences, Molavi Boulevard, PO Box 193, Semnan
35195, Iran. e-mail: amir822@yahoo.com
10.1177/0269215507084008
419
Intervention
The subjects were randomly assigned to one of
the two experimental groups: combination therapy
(Bobath plus electrical stimulation method) or
Bobath. Before starting the treatment protocol,
the subjects lower limbs were exposed for 10
minutes to infrared at a distance of 50 cm to
warm up the limbs. This was also done to ensure
the same skin temperature in all subjects, as the
afferent sensory signals may affect motor neuron
pool excitability in the central nervous system.21
The combination therapy group underwent 20
daily sessions of Bobath inhibitory techniques
and
neuromuscular
electrical
stimulation.
Bobath inhibitory techniques included applying
for 15 minutes passive movement of ankle
joint dorsi-flexion, knee joint extension, abduction
and external rotation of hip joint, which is
known as the reflex inhibitory pattern.4
Neuromuscular electrical stimulation included
9 minutes of supramaximal (25% over the
intensity needed to produce maximum contraction
of muscle) muscle stimulation. The stimulation
current included 100 Hz pulse stimulation (pulse
duration 0.1 ms, pulse interval 0.9 ms) which
was applied in surge mode (surge duration 4
seconds and rest between surge 6 seconds),
known as Faradic stimulation,22 on the tibialis
anterior muscle via cathode (over the neuromuscular junction of the muscle) and anode (over the
fibula head) electrodes.
420
Bobath therapy
group (N=20)
Losses (n=2)
Not completed because of:
a) Diseases
b) Private reason
Combination therapy
group (N=20)
Losses (n=3)
Not completed because of:
a) Diseases
b) Private reason
Outcome data
Before and after intervention
(N=18)
Figure 1
Outcome data
Before and after intervention
(N=17)
Measurements
The staff who assessed the outcomes measure
were different from the staff administering the
treatments and they were blinded from the
type of treatment each patient received. All
measurements were performed before and after
the 20 daily therapy sessions. Outcome measures
for each patient consisted of: (a) tonicity
evaluation by Modified Ashworth Index,23
(b) ankle joint dorsiflexion range of motion
(ROM) by hand-held goniometer, (c) ankle
dorsiflexor muscle manual strength test24 and the
evaluation of soleus muscle H-reflex amplitude.25
A hand-hold goniometer was used to measure
passive ankle joint dorsiflexion range of motion.
The axis of the goniometer was placed 2 cm below
the medial maleolous of the ankle joint, while its
fixed arm was placed along the long axis of leg and
its moving arm placed along the long axis of first
metatarsal bone. The reference position was the
right angle between foot and leg. The foot was
then moved passively to the end of ankle joint
Statistical analysis
To compare the possible effect of the Bobath
inhibitory technique with the combination
therapeutic effect of Bobath inhibitory technique
plus electrical stimulation, an intention-to-treat
analysis was used which involved all subjects
who were randomly assigned to their groups.
As all recorded measures were normal statistically,
independent Students t-test was used to compare
the baseline values and also to compare the mean
changes of the recorded values between the two
experimental groups. Paired sample t-test
was used to find any significant change in the
recorded values before and after intervention
within experimental groups.
Table 1
421
Results
Table 1 shows the measured parameters
before intervention in both groups; no significant
difference was found in the baseline values.
Comparison
between
the
measurement
parameters showed significant changes within
both combination and Bobath groups, so that
significant increases in the ankle joint dorsiflexion
ROM (P 0.0001) and dorsiflexion strength
(P 0.0001 and P 0.002, respectively) and
decrease in the gastrocnemius muscle tonicity
(P 0.0001) and H-reflex amplitude (P 0.0001)
were seen in both groups (Table 1).
Table 2 shows mean changes of measured
parameters after intervention in both experimental
groups. The comparison of mean changes showed
significantly higher ankle joint dorsiflexion ROM
(P 0.0001) in the combination group than in
the Bobath group. Statistically, lower calf muscle
Measured parameters
Before intervention
Combination
group
Bobath
group
Mean (SD)
Mean (SD)
After intervention
Between-groups Combination
group
P-value
0.75
3.5 (0.76)
3 (1.08)
0.69
0.25 (0.55)
0.8 (1.15)
0.07
0.73
Table 2
Bobath
group
Mean (SD)
Mean (SD)
Within-group Within-group
P-value
P-value
24.95 (9.57)
P 0.0001
1.9 (0.72)
P 0.0001
0.95 (0.83)
20.6 (9.68)
P 0.0001
1.9 (0.97)
P 0.0001
1.2 (1.51)
P 0.0001
0.24 (0.19)
P 0.0001
P 0.002
0.39 (0.16)
P 0.0001
Measured parameters
Ankle joint dorsiflexion ROM (degrees)
Plantarflexor muscle tonicity (Modified Ashworth Scale)
Dorsiflexor strength (graded from 0
(no contraction at all) to 5 (normal contraction))24
H/Mmax amplitude ratio
Combination group
Mean change (SD)
Bobath group
Mean change (SD)
P-value
11.4 (4.79)
1.6 (0.5)
0.7 (0.37)
6.1 (3.09)
1.1 (0.31)
0.4 (0.23)
0.0001
0.001
0.04
0.41 (0.29)
0.3 (0.28)
0.243
422
Discussion
This study has been designed to investigate the
effectiveness of a combination of neuromuscular
electrical stimulation and Bobath inhibitory
techniques on spasticity in spastic patients.
Our results indicated that the combination of
neuromuscular electrical stimulation and Bobath
techniques may be more effective in reducing
spasticity, as it caused lower ankle stiffness,
higher ROM in ankle joint dorsiflexion and
higher ankle dorsiflexor muscles strength. Several
studies have been designed to investigate the effect
of electrical stimulation on spasticity either in
transcutaneous or neuromuscular form.15,2729 By
searching MEDLINE, 17 studies were found
about the effects of neuromuscular electrical
stimulation on spasticity. Five of these studies
showed no significant change in spasticity,
while the other 12 studies reported some benefits
of neuromuscular electrical stimulation on
spasticity reduction. Hazlewood and colleagues
stated that neuromuscular electrical stimulation
may increase passive range of movement
among children receiving electrical stimulation
by reduction of muscle tone.17 However, in
two separate studies, the authors concluded
that electrical stimulation has no effect on the
spasticity.16,30 On the other hand it has
been claimed that different parameters used for
electrical stimulation may be the reason for the
different reported results.22 This was seen in the
Hines et al. study that reported no decrease in
spasticity in hemiplegic patients by functional electrical stimulation.30 However, most of the studies
indicate that neuromuscular electrical stimulation
may be an effective method for rehabilitation of
spasticity,27,31 as was shown in our study,
although the specific mechanism of this improvement remains uncertain.32 In a more recent study,
Ozer et al. showed that the combined use of neuromuscular electrical stimulation and bracing is
more effective than either alone.27 In 2005,
Carda and Molteni showed in a casecontrol
study that patients treated with adhesive taping
and botulinum toxin achieved a greater reduction
in spastic hypertonia than those treated with transcutaneous electrical stimulation therapy after
botulinum toxin therapy.16 In another study the
therapeutic effect of transcutaneous electrical stimulation and oral baclofen was compared in the
treatment of spasticity in patients with multiple
sclerosis
and
authors
suggested
that
transcutaneous electrical stimulation may be
applied as a supplement to medical treatment in
the management of spasticity.28
Functional electrical stimulation has been used
for motor-complete spinal cord-injured patients
and no benefit of such a therapy was found on
spasticity.29 However, it should be remembered
that their subjects had no motor control from
the upper motor neuron system, unlike patients
in other studies who had some control from the
upper motor neuron system.3234 These studies
showed significant spasticity rehabilitation after
neuromuscular electrical stimulation in hemiplegia
and cerebral palsy patients.
Although our findings showed significantly
improved spasticity indexes, such as joint stiffness
and joint passive range of motion in the combined
group, no significant changes were found in the
H-reflex amplitude as reported by others.28
H-reflex amplitude has been introduced as an
index for the evaluation of spasticity,35 although
different studies present different reports about its
changes. Geoulet and colleagues reported no
H-reflex amplitude changes after reduction in
the gastrocnemius colonus due to electrical
stimulation therapy.36 Conversely, Gaft and colleagues showed that electrical stimulation therapy
may reduce spasticity and H-reflex amplitude as
well.37 Later in 2001, these contradictory reports
were also reported by other authors.38,39
It has been shown that an abnormal pattern in
the H-reflex amplitude may be seen in spastic
patients regarding the level of muscle tonicity.35
Tanino and colleagues reported that after muscle
electrical stimulation, there is no such
pattern of H/M ratio changes in normal subjects.40
They suggested that the main reason is the
and may help to provide better functional performance for these patients. Therefore, it may be
recommended
from
these
findings
that
electrical stimulation may be used as a standard
therapeutic protocol with Bobath inhibitory
techniques for treatment of spasticity in the
rehabilitation clinic, before starting any motor
control therapeutic protocol. However, as this
study showed the benefits of neuromuscular
electrical stimulation on spastic muscles, further
studies are needed to investigate the long-term
effects of electrical stimulation on spasticity and
also on the functional activity of spastic patients.
It would also be recommended to design the study
to compare the beneficial effects of neuromuscular
electrical stimulation on agonist muscles versus
antagonist muscles to find the most effective
protocols for the treatment of spasticity.
Clinical message
In stroke patients, therapy that combines
Bobath inhibitory technique with electrical
stimulation may help to reduce spasticity.
References
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5
Conclusion
The results of this study showed that combination
therapy with neuromuscular electrical stimulation
and Bobath inhibitory technique may reduce spasticity in patients with upper motor neuron lesions
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